United States onlyBusinessAnalyst - Clinical Analyst & Coding Specialist
Location:Fully Remote
Interview Process:1round, Virtual/Online
Duration:12 Months
Employment Type: Contract
Experience Required: 08+ Years
Candidate Location:Candidate MUST be a SC resident. No relocation allowed.
Project Scope:
We are seeking anexperienced Business Analyst – Clinical Analyst & Coding Specialist tosupport Medicaid policy, coding analysis, claims processing, and MMISinitiatives for a large healthcare and government environment. This role willserve as a subject matter expert (SME) supporting medical coding compliance,coding updates, policy remediation, and Medicaid business process improvements.
The ideal candidatewill have strong experience in medical coding, healthcare insurance operations,Medicaid claims processing, and payer systems, along with a clinical backgroundand the ability to collaborate with both technical and business teams. Thisrole will also contribute to future MMIS modernization and replacementinitiatives.
KeyResponsibilities:
- Serve as a subject matter expert (SME) formedical coding methodologies, Medicaid policy, and healthcare claimsprocessing.
- Support annual, quarterly, and ad hoc ICD-10,CPT, and HCPCS coding updates received from CMS.
- Perform analysis of medical coding changes andassess impact on business processes, claims adjudication, and systemfunctionality.
- Conduct initial code reviews and determine thescope and business impact of coding updates.
- Prepare and distribute coding change listings forreview by Medicaid program teams and reference administration staff.
- Collaborate with policy owners, stakeholders,developers, and business teams to support change requests and MMISenhancements.
- Participate in MMIS modernization and replacementproject meetings, providing coding and business process expertise.
- Research business rules, operationalrequirements, and process models to develop recommendations and solutions.
- Maintain business rules, coding documentation,requirements repositories, and process documentation.
- Facilitate meetings with agency personnel,stakeholders, and operational teams.
- Support policy remediation efforts and ensurealignment between coding standards and operational workflows.
- Assist with development and maintenance oftraining documentation and process materials.
- May review patient records against establishedmedical necessity criteria as backup support.
- Work collaboratively with cross-functional teamssupporting Medicaid operations and healthcare initiatives.
Required Skills& Experience:
- 5+ years of experience in healthcare insurance,medical review, program integrity, or appeals
- 5+ years of experience working with ITdevelopers/programmers in a payer environment
- 5+ years of hands-on medical coding experience ina payer environment
- 5+ years of Strong expertise in ICD-10, CPT, andHCPCS coding methodologies and translation
- 5+ years of Strong understanding of anatomy,physiology, pharmacology, and medical terminology
- 3+ years clinical experience in a healthcareenvironment (strong clinical assessment and critical thinking skills.)
- Experience supporting Medicaid operations andMMIS systems
- Strong analytical, documentation, and businessrequirements gathering skills
- Excellent written and verbal communication skills
·Proficiency with Microsoft Office Suite
Preferred Skills:
- 5+years of experience in policy remediation
- 5+years of experience with claims processing systems
- 5+years of Experience using: Optum Encoder, Other medical coding softwareplatforms
- 3+years of clinical experience in a healthcare environment
- Strongclinical assessment and critical-thinking skills
- Experience supporting government healthcare ormanaged care operations
License
Musthave current, active, and non-restricted licensure by the State of SouthCarolina Board of Nursing as a Registered Nurse.
CertificationCurrently credentialed as CPC (Certified Professional Coder) or as CCS(Certified Coding Specialist). ICD-10 Proficiency demonstrated by exam; or ableto become certified within one year of employment.
AU, CA + 3 more